Interventional radiology-assisted transgastric endoscopic drainage of peripancreatic fluid collections.

Summary: Peripancreatic fluid collections (PFCs) occur as a consequence of pancreatitis. Most PFCs resolve spontaneously, although 1%-2% persist and may require intervention. Conventional transluminal endoscopic drainage methods require the PFC to be bulging into the gastric wall; however, it is not uncommon for this to be absent. Imaging guidance for transluminal endoscopic PFC drainage allows the endoscopist to localize nonbulging pseudocysts that cannot be localized using endoscopy alone, to identify and avoid vascular structures between the cyst and the gastric lumen, and to reveal solid or necrotic components within the pseudocyst cavity. Although endoscopic ultrasound (EUS) has been used to meet this need, timely access to therapeutic EUS remains a limiting factor at many centres. We report our technique and experience performing transgastric endoscopic drainage of PFCs under computed tomography (CT) interventional radiology guidance.

Morbidity of hand-assisted laparoscopic splenectomy compared to conventional laparoscopic splenectomy: a 6-year review.

BACKGROUND: Laparoscopic splenectomy (LS) has several advantages over the open procedure but can be technically demanding when performed in patients with massive splenomegaly. We hypothesized that patients who undergo hand-assisted LS (HALS) may experience the benefits of LS while having their enlarged spleens removed safely. METHODS: We reviewed the charts of patients who underwent HALS or LS between January 2003 and June 2008. Evaluated parameters included intraoperative and early postoperative morbidity and mortality, conversion to open surgery, need for blood transfusion, length of postoperative hospital stay, patient demographics, diagnosis leading to splenectomy, splenic weight and number of postoperative days to resuming normal diet. Differences were analyzed while controlling for splenic weight and malignant diagnosis using multiple linear and logistic regression analysis. RESULTS: In all, 103 patients underwent splenectomy (23 HALS, 80 LS). Patients who had HALS were older and had larger spleens, and a greater proportion had malignant diagnoses. We observed no significant differences in morbidity, conversion to open surgery or need for blood transfusion. The mean length of postoperative stay, duration of surgery and days to resuming full diet were longer in the HALS group. No patients died. No group differences were significant after controlling for splenic weight and malignant diagnosis. CONCLUSION: The morbidity associated with HALS is comparable to that with LS. The longer duration of surgery and hospital stay for HALS patients was likely related to greater splenic weight, older age and greater proportion of malignant diagnoses. Hand-assisted LS is a viable alternative to open surgery in patients with massive spleens.

Hydronephrosis in children with abdominal and pelvic neoplasms: outcome and survival analysis of a single center pediatric oncology series.

PURPOSE: We ascertained the incidence and outcome of hydronephrosis related to abdominal or pelvic neoplasms and survival in pediatric patients. MATERIALS AND METHODS: We retrospectively reviewed our institutional oncology database between January 1995 and November 2009. We reviewed the charts of all children with intra-abdominal (nonrenal) and pelvic neoplasms. RESULTS: Of the 366 patients whose charts were reviewed 66 (18%) had hydronephrosis at some point during treatment, including 12 with hydronephrosis that was not caused by the neoplasm and 1 who was lost to followup, leaving 53 with malignant obstruction. Of the remaining patients hydronephrosis resolved in 34 (64%) with treatment for the primary neoplasm alone while in 19 (36%) hydronephrosis persisted after primary oncological treatment. Univariate analysis revealed that patients with persistent hydronephrosis (p = 0.025), those with urological intervention (p = 0.05) and those with high stage disease (p <0.001) had statistically significantly worse overall survival. On Cox multivariate analysis only disease stage remained statistically significant (p = 0.004). CONCLUSIONS: Analysis of this group revealed that pediatric nonrenal abdominal and pelvic tumors are associated with hydronephrosis in about 20% of cases. Approximately 60% of these cases resolved with treatment for the primary tumor alone while 13% required specific urological intervention for urinary tract involvement or compression. Patients with pediatric malignant ureteral obstruction had a 20% 5-year mortality rate. The main predictive factor was primary disease stage.

Single-incision transumbilical laparoscopic splenic cyst unroofing: first reported case.

Single-incision laparoscopic surgery is an emerging minimally invasive approach. When using the single-incision laparoscopic surgery approach, the surgeon operates almost exclusively through a single point of entry, usually the patient's umbilicus. This approach is steadily gaining popularity among minimally invasive surgeons, as it combines the cosmetic advantage of Natural Orifice Translumenal Surgery with the technical familiarity of conventional laparoscopic surgery. In this report, we describe our implementation of the single-incision laparoscopic approach to perform an unroofing of a posttraumatic splenic cyst; in this case, the entire procedure is performed through a 2-cm intraumbilical incision.

Single-incision laparoscopic placement of an adjustable gastric band versus conventional multiport laparoscopic gastric banding: a comparative study.

Single-incision laparoscopic surgery (SILS) is rapidly becoming the focal point of attraction for early adopters of minimally invasive surgery nationwide. Having achieved a rapid crossover to the realm of advanced surgical procedures, SILS has shown remarkable versatility and adaptability, making it no longer limited to basic laparoscopic procedures. We report our experience performing laparoscopic placement of gastric bands with an emphasis on comparison of the single-incision laparoscopic approach with the conventional multiport laparoscopic approach. From December 2008 to September 2009, 27 patients underwent laparoscopic placement of an adjustable gastric band at Michigan State University/Kalamazoo Center for Medical Studies. This included 15 patients who underwent single-incision laparoscopic gastric banding and 12 patients who underwent conventional multiport laparoscopic gastric banding procedures. The overall pain score was found to be significantly less in the SILS group than that for the conventional multiport laparoscopic gastric banding group with a statistically significant P value of 0.012. The operating time was found to be significantly less in the multiport group with a P value of 0.000. Differences in immediate postoperative pain scores, analgesia, and the overall length of hospital stay were found to be statistically insignificant. Single-incision laparoscopic gastric banding is associated with significantly less overall postoperative pain than the conventional laparoscopic approach; in addition, it provides improved cosmetic outcome despite a modest increase in operative time.

Feasibility of single-access laparoscopic sleeve gastrectomy in super-super obese patients.

BACKGROUND: The sleeve gastrectomy procedure has been gaining popularity because of its simplicity and favorable outcomes. This study reports the experience with a single-access approach to laparoscopic sleeve gastrectomy in super-super obese patients. METHODS: Four super-super obese patients having a mean body mass index of 62.7 kg/m(2) underwent single-access laparoscopic sleeve gastrectomy. The same perioperative protocol and operative techniques were implemented for all 4 patients. RESULTS: A total of 4 single-access laparoscopic sleeve gastrectomies in super-super obese patients were successfully performed using this technique. Mean operating time was 126 minutes. One patient required the insertion of an additional trocar. There were no mortalities or postoperative complications noted. Most comorbidities either improved or resolved during a mean follow-up of 5.3 months. CONCLUSION: Single-access laparoscopic sleeve gastrectomy in the super-super obese is safe, feasible, and reproducible.

Single port access transumbilical laparoscopic Roux-en-Y gastric bypass using the SILS Port: first reported case.

The emergence of natural orifice translumenal endoscopic surgery (NOTES) has brought significantly more attention to the single-incision transumbilical laparoscopic approach (SILS) for minimally invasive surgery. SILS combines the cosmetic advantage of NOTES with the technical familiarity of the conventional multiport laparoscopic approach. Additionally, SILS does not involve penetration of an organ, nor does it involve the steep learning curve and costly instruments associated with NOTES. Given these advantages, the authors believe that the single-incision transumbilical approach highlights the future direction of minimally invasive surgery. However, because of the associated technical challenges, the single-incision approach has not quite yet achieved the crossover to advanced surgical procedures that conventional multiport laparoscopy achieved in its early years. In this report, the authors present what is, to the best of their knowledge, the first reported case of a single-port access laparoscopic Roux-en-Y gastric bypass using the SILS Port placed through a single intraumbilical skin incision.

Incidentally-Discovered Squamous Cell Carcinoma after Endoscopic Sphincterotomy.

The association between the development of bladder cancer and chronic bladder irritation is well established in the literature. Chronic urinary tract irritation can be the result of bacterial infections, foreign bodies, trauma of repeated catheterization, neurogenic bladder, urolithiasis, or chronic bladder outlet obstruction, all which have been implicated in the pathogenesis of non-bilharzial squamous cell carcinoma of the bladder (SCC). With many of the aforementioned factors present in patients with spinal cord injury, several retrospective studies have demonstrated a 16-28 fold increased relative risk of bladder cancer, with SCC accounting for 10 times more cases of bladder cancer compared to the general population. In this report, we present the case of incidentally-discovered SCC of the bladder found within sphincter/prostate chips of a patient with neurogenic bladder due to spinal cord injury n clean intermittent catheterization ho underwent sphincterotomy with negative cystoscopic findings.

Oncological outcomes of partial nephrectomy for tumours larger than 4 cm: A systematic review.

INTRODUCTION: Many medical associations recommend nephron-sparing surgery (NSS) for tumours larger than 4 cm amenable to partial nephrectomy (PN). These recommendations are, however, mostly based on isolated reports. We systematically review the oncological outcomes of partial nephrectomy procedures performed for tumours larger than 4-cm. METHODS: A PubMed search was carried out using keywords "partial nephrectomy" and "nephron sparing" for records dating back to 1995. In total, 2136 abstracts were analyzed; from these, 174 studies were scrutinized. We identified 32 manuscripts reporting size-specific cancer-specific survival rates for masses greater than 4 cm. From each of these studies, we recorded the number of PN, tumour diameter, follow-up duration, 5- and 10-year recurrence, overall and cancer-specific survival rates (OS, CSS). We also calculated weighted OS and CSS rates. RESULTS: This systematic review includes 2445 patients with renal tumours larger than 4 cm who underwent PN: 1858 patients with tumours between 4 to 7 cm, 410 patients with tumours larger than 7 cm and 177 patients with tumours greater than 4 cm (exact size unknown). Our analysis revealed weighted 5-year CSS rates of 95.4%, 86.2% and 93.9% for tumours 4 to 7 cm, >7 cm, and all tumours >4 cm, respectively. The respective 5-year OS rates were 84.7%, 76.4%, and 84.7%. CONCLUSIONS: We found excellent 5-year CSS and OS rates for patients with tumours 4 to 7 cm treated with PN. These outcomes compare favourably to those reported in historical radical nephrectomy (RN) series for similarly sized tumours. Thus, PN is an acceptable and often preferred treatment for renal masses >4 cm which are amenable to nephron-sparing procedures.

Three trocar laparoscopic Roux-en-y gastric bypass: a novel technique en route to the single-incision laparoscopic approach.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass is the gold standard bariatric procedure. Typically, the procedure necessitates five to seven small skin incisions for trocar placement. The senior author (AA Saber) has developed a three-trocar approach for laparoscopic Roux-en-Y gastric bypass. METHODS: Sixteen patients underwent triple-incision laparoscopic Roux-en-Y gastric bypass between May 2009 and August 2009. The same surgeon performed all surgical interventions. The umbilicus was the main point of entry for all patients and the same operative technique and perioperative protocol were used in all patients. RESULTS: A total of sixteen triple-incision laparoscopic Roux-en-Y gastric bypasses were performed. The procedures were successfully performed in all patients. Mean operating time was 145.4 min. None of the patients required conversion to an open procedure. There were no mortalities or post-operative technical complications noted during the immediate post-operative period. CONCLUSION: Three trocar laparoscopic Roux-en-Y gastric bypass is safe, technically feasible and reproducible. This technique may be considered a "precursor" to single-incision laparoscopic Roux-en-Y gastric bypass.

Simple technique for single incision transumbilical laparoscopic appendectomy.

INTRODUCTION: Acute appendicitis is one of the most commonly encountered surgical problems in everyday practice. With the recent increase in popularity of single incision laparoscopic surgery (SILS), several techniques for SILS appendectomy have already been described. We herein describe our own simplified technique for single incision transumbilical laparoscopic appendectomy. MATERIALS AND METHODS: From December 2008 to August 2009, a total of 26 patients consented for single incision laparoscopic appendectomy for acute appendicitis. Preoperative, intraoperative and postoperative data were collected. RESULTS: Our technique was successful in 19 out of 26 (73.1%) patients, while seven patients required the placement of additional trocars. None of the patients needed conversion to an open approach. Mean OR time was 45.9 min. The mean length of stay was 1.1 day. Only one patient had developed postoperative umbilical wound infection. CONCLUSION: Our technique for single incision laparoscopic transumbilical appendectomy is safe feasible, and reproducible. Prospective randomized studies comparing the single incision laparoscopic approach with its conventional multiport counterpart are necessary to confirm the conclusions of our early experience.

Single-incision laparoscopic sleeve gastrectomy versus conventional multiport laparoscopic sleeve gastrectomy: technical considerations and strategic modifications.

BACKGROUND: Since its inception, minimal access surgery has been a dynamic field, experiencing successive leaps in technique and instrumental design. Each improvement in minimal access surgery must demonstrate that patients benefit from the change in approach, without compromising the outcome. The present study presents the technical considerations and strategic modifications for single-incision laparoscopic sleeve gastrectomy. We also compared the newly adopted single-incision laparoscopic approach with conventional multiport laparoscopic sleeve gastrectomy. METHODS: Of the 26 patients included in the present study, 14 underwent single-incision laparoscopic sleeve gastrectomy and 12 underwent conventional multiport sleeve gastrectomy. All procedures were performed by the same surgeon (A.A.S.) during a 12-month period from September 2008 to August 2009 at Michigan State University Kalamazoo Center for Medical Studies. RESULTS: The Mann-Whitney U tests showed with 95% confidence that the difference in pain scores and length of hospital stay in the single-incision laparoscopic sleeve gastrectomy group were statistically significant. A modest increase occurred in the operative time in the single-incision laparoscopic sleeve gastrectomy group. This difference was the least statistically significant of all variables (P = .055). CONCLUSION: Single-incision laparoscopic sleeve gastrectomy was associated with less postoperative pain, a lower need for analgesia, and a decreased length of hospital stay compared with conventional multiport laparoscopic sleeve gastrectomy. This was achieved without decreasing the quality of surgery or the outcomes offered by the conventional multiport counterpart.

Early experience with SILS port laparoscopic sleeve gastrectomy.

BACKGROUND: Ever since single-incision laparoscopic surgery was introduced 12 years ago, it has undergone many attempts to improve its feasibility and accessibility. We herein are reporting our early experience with SILS Port as a multichannel single-port access to perform laparoscopic sleeve gastrectomy. METHODS: Six morbidly obese patients underwent laparoscopic sleeve gastrectomy using the SILS Port as a common point of entry for 3 trocars. The same perioperative protocol was implemented for all 6 patients. RESULTS: All 6 SILS Port laparoscopic sleeve gastrectomies were successfully performed using this technique. The 3 super-obese male patients with central obesity required the insertion of a 5-mm subxiphoid trocar. The mean operating time was 123 minutes. There were no mortalities or postoperative complications noted during the immediate follow-up period of all 6 patients. CONCLUSION: SILS gastrectomy using SILS Port is safe and feasible.

Early experience with single-access transumbilical adjustable laparoscopic gastric banding.

BACKGROUND: Laparoscopic adjustable gastric banding is the most common bariatric procedure performed worldwide; since FDA approval was granted for it in June 2001, the procedure has been steadily gaining popularity in the USA. We herein report our early experience with single-access transumbilical laparoscopic gastric banding. This approach to the procedure is performed mainly through a single incision in the umbilicus. This single incision is also utilized for the implantation of the port for subsequent band adjustments. METHODS: Eight patients were carefully selected (body mass indices between 35 and 45 kg/m(2) with peripheral obesity), and each underwent laparoscopic gastric banding using this single-incision transumbilical technique. The same surgeon performed all surgical interventions. For each of the eight patients, the same perioperative protocol and operative techniques were implemented. RESULTS: Seven out of eight attempted single-access transumbilical laparoscopic gastric banding procedures were successfully performed using this technique. Mean operative time was 105 min. One out of the eight patients required the insertion of an additional trocar. There were no mortalities or postoperative complications noted during the mean follow-up period of 2.6 months. CONCLUSION: Single-access transumbilical laparoscopic adjustable gastric banding is a safe and feasible evolving approach in a selected group of patients. The intraumbilical location of the implanted port facilitates access for subsequent adjustments and provides patients with an improved cosmetic outcome.

Early experience with single incision transumbilical laparoscopic adjustable gastric banding using the SILS Port.

BACKGROUND: The rapid progression of single-incision laparoscopic surgery (SILS) into the realm of advanced surgical procedures has been fueled in recent years by the development of flexible instrumentation necessary to restore triangulation lost in the divergent nature of this approach, and multichannel ports that addressed the challenges regarding the limited range of movement of trocars in close proximity. We herein are reporting our early experience using the SILS Port to perform single incision transumbilical laparoscopic gastric banding in five of our patients. METHODS: Five carefully selected female patients (body mass indices between 35 and 45kg/m(2) with peripheral obesity) underwent laparoscopic gastric banding using this single incision transumbilical technique. The same surgeon performed all surgical interventions. For all five patients, the same perioperative protocol and operative techniques were implemented. RESULTS: A total of five single incision transumbilical laparoscopic gastric banding procedures were successfully performed using this technique. Mean operative time was 111min. There were no mortalities or postoperative complications noted during the mean follow-up period of 1.5 months. CONCLUSION: Single incision transumbilical laparoscopic adjustable gastric banding using SILS Port is a safe and feasible evolving approach. The intraumbilical location of the implanted port facilitates access for subsequent adjustments and provides patients with an improved cosmetic outcome.

Single-incision transumbilical laparoscopic sleeve gastrectomy.

BACKGROUND: Laparoscopic sleeve gastrectomy has been gaining popularity due to its simplicity and outstanding results. This procedure is no exception to attempts aimed at minimizing abdominal port access. In this article, the senior author (AAS) presents his technique for an entirely transumbilical single-incision approach where no extraumbilical incisions are necessary. MATERIALS AND METHODS: Seven patients underwent laparoscopic sleeve gastrectomies using this single-incision, totally transumbilical technique. The same surgeon (AAS) performed all surgical interventions. The same perioperative protocol and operative techniques were implemented for all the patients. RESULTS: A total of 7 single-incision transumbilical laparoscopic sleeve gastrectomies were successfully performed using this technique. Two patients required lysis of adhesions, and 1 patient underwent an umbilical hernia repair during the procedure. Mean operating time was 143 minutes. One of the patients required the insertion of an additional trocar. There were no mortalities or postoperative complications noted during the mean follow-up period of 1.5 months. CONCLUSIONS: Single-incision laparoscopic sleeve gastrectomy performed entirely through the umbilicus is safe, technically feasible, and reproducible.